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A Pain in the Butt: Rehabilitation for Hip Pathologies
Kelly M. Heffron, PT, DPTMichelle Fuleky, PT, DPT
Suzi Collins, PTLaura Johnson, PT, DPT, MTC, FAAOMPT
August 10, 2013
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ObjectivesI. Identify differential diagnoses for hip painII. Identify common hip pathologiesIII. Select key elements of a hip pain
evaluation/examinationIV. Understand the relationship between the foot, core
and hip as related to hip painV. Explain femoral acetabular impingementVI. Introduce protocol for rehabilitation of femoral
acetabular impingement
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360 Sports Medicine Collaborative care for medical, surgical,
rehabilitative, preventative and sports enhancement services
27 ortho/sports PTs at 5 sites Physical therapists’ roles: Post‐operative rehabilitation
• First post‐operative visit and PT evaluation conducted with surgeon and PT present when possible
Non‐operative injury rehabilitation Injury prevention workshop Community outreach to educate
athletes, parents, trainers and coachesA PROGRAM OF
Differential Diagnosis for Hip Pain Sacroiliac dysfunction 1
Anterior or posterior innominate rotation Ilium inflare or outflare Upslip or Downslip Sacral torsion Flexed or extended sacrum
Lumbar spine involvement1 Discogenic pathology Spondylolysis or spondylolisthesis Radiculopathy and/or neural impingement Lumbar paraspinal muscle strain
Red flags for hip pain related to hip pathology 2
Presence of a limp Groin pain Limited internal hip rotation
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3
Common Hip Pathologies Trochanteric bursitis Illiotibial band tightness/friction
disorder Piriformis syndrome Labral tear Avulsion fracture Anterior inferior iliac spine Iliac crest
Muscle strain Femoral acetabular impingement
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4
Key Elements for Hip Examination
History Identify
• Mechanism of initial injury• Movements that reproduce symptoms• Sport involvement• Foot wear (shoes, orthotics, etc.)
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Key Elements for Hip Examination Objective Measures
Postural screen• Sagittal, frontal and transverse plane assessment
Palpation Range of motion (ROM) Flexibility
• Hamstrings, quadriceps, piriformis, iliotibial band/tensor fascia lata, gastrocnemius/soleus
Strength• Core, gluteus medius, gluteus maximus, gluteus minimus, quadriceps, hamstrings, gastrocnemius
Special tests• Rule out low back and/or sacroiliac diagnoses • Determine hip diagnosis
Functional screen• Double leg squat, single leg squat/dip, heel raise, functional step up, double leg jump, single leg jump, walk, run
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Linking the Foot and Hip Postural assessment finding Excessive
subtalar pronation 5
Causes of: Ligamentous laxity at the ankle joint Weak hip abductors Poor mechanical alignment of lower limb during high impact activities
Results in: Tibial internal rotation
• Induces a compensatory femoral internal rotation
Genu valgum• Increases Q angle
Femoral anteversion
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6
Linking the Foot and Hip Treatment for excessive pronation
Orthotic management Demonstration
Posterior tibialis strengthening (isolated) Towel curl Wiper Big toe push
Gluteus medius strengthening (isolated)23 Clam Side‐lying hip abduction Single leg bridge Lateral band walk Single leg squat
Link increased isolated strength to functional skills to change movement patterns
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Linking the Core and Hip “CORE” does not mean “Six‐pack” Four parts of the core:
I. DiaphragmII. Pelvic floorIII. Transverse abdominusIV. Multifidus
Function of the core Stabilize lumbar spine Increase stability and control for functional skillsGenerate increased power for functional skills
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7
Linking the Core and Hip
Core stabilization will: Decrease overuse of hip flexor tendons Reduce lumbar extension to keep the body operating in neutral
Improve balance and control Reduce asymmetrical loading at the hip joint
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8
Femoral Acetabular Impingement 9“Femoral acetabular impingement is a pathological condition leading to abutment between the proximalfemur and the acetabular rim.” 9
Two Types:I. Pincer lesion
Soft tissue abnormality = Excessive coverage of the acetabulum• Repetitive contact of the over‐covered acetabulum rim and femoral neck with hip flexion and/or internal rotation will create impingement.
II. CAM lesion Bony abnormality= Non‐spherical femoral head
• Repetitive contact with hip flexion and/or internal rotation will create impingement due to the abnormal femoral head shape.
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10
Femoral Acetabular Impingement9
Current non‐operative management Discontinuation of sport Avoid repetitive hip flexion and internal rotation Non‐steroidal anti‐inflammatory agents ??? Physical Therapy ???
According to Banerjee, et al., “Surgical intervention is a more realistic option. Physiotherapy has no role in the management of FAI and hence not recommended.”
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11
Protocol for Non‐Operative Femoral Acetabular Impingement
Protocol for Non‐Operative Femoral Acetabular Impingement Purpose: To determine if physical therapy is effective as a non‐operative
treatment for FAIGOALS:1. Reduce pain at affected hip to 0‐2/10 on the Numeric Pain Scale12 with:
Repetitive transitions from supine sit, sit stand and stand sit over at least 10 minutes
Ambulation on varied terrain (i.e. flat ground, grass, sand or incline) for at least 20 minutes
Seated position for at least 60 minutes Run and/or jog for at least 30 minutes Sport specific tasks like cut, jump and pivot for at least 30 minutes
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Protocol for Non‐Operative Femoral Acetabular Impingement
2. Return patient to prior level of function without the need for surgical intervention through: Improved postural alignment to locate neutral spine and improve body awareness Increased strength and endurance of core stabilizers 13,14
• Achieve a 4/5 on the Double Straight Leg Test and maintain neutral alignment for 60 seconds in prone plank
Increased strength and endurance of proximal hip muscles (i.e. Gluteus medius, Gluteus maximus, Gluteus minimus)15,16,17
• Achieve a 5/5 on Manual Muscle Testing (MMT)18 and perform 10 consecutive single leg dips
Increased flexibility of lower extremity muscles that have attachments at the hip and/or pelvis19
• Meet all standards outlined for the flexibility tests
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Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Posture13,14
BEGINNER‐ADVANCED Train the patient to achieve neutral spine
I. Address all postural deviations with home program exercises.
Lumbo‐pelvic mobility trainingI. Hook‐lying pelvic tilt anterior
posterior and posterior anteriorII. Quadruped cat/camelIII. Standing pelvic tilt anterior
posterior and posterior anteriorIV. Squat with anterior pelvic tilt
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20
Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Core Stabilization13,14
BEGINNER Transverse abdominus (TrA) recruitment
I. Breathing with abdominal draw in maneuver
Multifidus (MTF) recruitmentI. Prone posterior pelvic tilt with
unilateral lower extremity elevation TrA & MTF engagement with lower and/or
upper extremity movementI. Single knee fall outII. MarchIII. Heel slideIV. Contralateral upper extremity and
lower extremity extension
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Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Core Stabilization13,14
INTERMEDIATE Bird‐dog
I. Upper extremities onlyII. Lower extremities onlyIII. Contralateral upper and lower
extremity Plank
I. Weight bear through hands and toes
II. Weight bear through elbows and toes
Swiss ball kneeling upper extremity roll‐out
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Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Core Stabilization13,14
ADVANCED Rotational stability activities
I. Seated • Stable surface• Unstable surface
II. Kneeling • Stable surface• Unstable surface
III. Standing• Stable surface• Unstable surface
Rotational mountain climbersA PROGRAM OF
21
Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Proximal Strengthening15,16,17
BEGINNER Clamshell
(hip flexed 30 degrees) Side‐lying hip abduction
(hip extended 30 degrees) Double leg bridge
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Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Proximal Strengthening15,16,17
INTERMEDIATE Standing single leg balance (hip flexed to 20 degrees)
I. Maintain neutral pelvis with no movement• Stable surface• Unstable surface
II. Maintain neutral pelvis with hip abduction, extension, and flexion
• Stable surface• Unstable surface• Progress to resisted
Lateral band walks (knees and hips 30 degrees of flexion) Lunges (<90 degrees hip flexion)
I. ForwardII. LateralIII. Transverse
Single leg bridge
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L2
Slide 21
L2 I cropped the picture, which will allow you more space to increase font. Laura, 6/21/2013
Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Proximal Strengthening15,16,17
ADVANCED Single leg squats Single leg deadlift Double and single limb
plyometrics (specific to PLOF)I. ForwardII. LateralIII. Transverse
Agility drillsI. ForwardII. LateralIII. Transverse
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Protocol for Non‐Operative Femoral Acetabular Impingement:Therapeutic Exercises for Lower Extremity Flexibility19
STATIC STRETCHING Hamstring Gastrocenmius Piriformis Quadriceps Iliotibial band Hip adduction Double knee to chest
DYNAMIC STRETCHING Toy Soldier Hip internal rotation Hip external rotation Butt kicks High knees Spider walk Inch Worm
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Thank You for all of Your Contributions
Dr. Andrew Pennock Jessica Garfin, PT, DPTDanielle Sidoti, PT, DPTNan Haney, PT, Physical Therapy ManagerAlexa Kratze, Director, Developmental Services Programs
Linda Heartness, Administrative AssociateEric Julienne, Rehabilitation AidePhysical Therapy Team
ANY QUESTIONS???
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References1. Reimen MP. The SI Joint and Pelvic Girdle. Franklin, Tenn: North American Seminars; 20092. Brown MD, Gomez‐Marin O, Brookfield KFW, Stokes P. Differential diagnosis of hip disease versus spine disease. Clin Orthop.
2004:419;280‐284.3. http://perfectgolfswingreview.net/Pelvis.jpg. Accessed June 14, 2013.4. http://www.sports‐injury‐info.com/image‐files/hip‐pain‐snapping‐hip.jpg. Accessed June 14, 2013.5. Black J, Richardson,J. The Butt/Foot Bias: Solving the Patellofemoral Dilemma. Combined Sections Meeting. San Diego; 2013.6. http://www.vietnamchiropractic.com/en/foot‐orthotics‐i28.html. Accessed June 14, 2013.7. http://cenkchiro.com/img/imagery/c1.jpg. Accessed June 14, 2013.8. http://blog.seattlepi.com/gracefulaging/files/library/Core_Muscles.jpg. Accessed June 14, 2013.9. Banerjee P, Mclean CR. Femoroacetabular impingement: a review of diagnosis and management. Curr Rev Musculoskelet
Med. 2011:4:23‐32.10. http://jointpain.md/images/fais.jpg. Accessed June 14, 2013.11. http://www.topendsports.com/image/cache/warning‐signs/golf/golfer_500_copyright.jpg12. Dutton M. Orthopaedic Examination, Evaluation and Intervention. Philadelphia, Penn: McGraw‐Hill; 2008.13. Goudzwaard AL, Vleeming A, Stoeckart R, Snijders J, Mens JMA. Insufficient lumbopelvic stability: a clinical, anatomical and
biomechanical approach to ‘a‐specific’ low back pain. Manual Therapy. 1998:3(1);12‐20.14. Hodges PW. Is there a role for transverse abdominus in lumbo‐pelvic stability? Manual Therapy. 1999:4(2);74‐86. 15. Distefano LF, Blackburn JT, Marshall SW, Padua DA. Gluteal muscle activation during common therapeutic exercises. J Orthop
Sports Phys Ther.2009:39;532‐540.
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References16. Ayotte NW, Stetts DM, Keenan G, Greenway EH. Electromyographical analysis of selected lower extremity muscles during 5
unilateral weight‐bearing exercises. J Orthop Sports Phys Ther. 2007:37:48‐55.17. Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports
Phys Ther. 2005:35;487‐494. 18. Magee DJ. Orthopedic Physical Assessment. Philadephia, Penn: Saunders; 2002.19. Flynn TW, Cleland JA, Whitman JM. Users’ Guide to the Musculoskeletal Examination: Fundamentals for the Evidence‐Based
Clinician. Minneapolis, Minn: Evidence in Motion: 2008.20. http://rechargehq.com.au/wp‐content/uploads/2012/07standing‐posture1.jpg. Accessed June 14, 2013.21. http://www.bicycling.com/sites/default/files/images/russian‐twist‐2.jpg. Accessed June 14, 2013.22. Pierce CM, Laprade RF,Wahoff M, O’Brien L, Philippon M. Ice hockey goaltender rehabilitation including on‐ice
progression, after arthroscopic hip surgery for femoroacetabular impingement. J Orthop Sports Phys Ther. 2013:43(3);129‐141.
23. Teyhen DS, Robertson J. Strengthening your hip muscles: some exercises may be better than others. J Orthop Sports PhysTher. 2013:43(2);65.
24. Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine‐wire electrodes. J Orthop Sports Phys Ther. 2013:43(2);54‐60.
25. Austin AB, Souza RB, Meyer JL, Powers CM. Identification of abnormal hip motion associated with acetabular labralpathology. J Orthop Sports Phys Ther. 2008:38(9):558‐565.
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